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11030015CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22265 CARTA BLANCA ST CONTRACTOR: VAGGIQNE PROPERTIES PERMIT NO: 11030015 OWNER'S NAME: LICENSED CONTRACTOR'S DECLARATION License Class -6 tic. d Contractor 1 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source eg Date — OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). hereby affirm under penalty of perjury one of the following three declarations: 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 1 certify that 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, cosh and expenses which may accrue against said City in consequence of the gi of this permit. Additionally, the applicant understands and will comply V, „ non -point source regulations per the Cupertino Municipal Code, Section S.18. Signature Date 12747 SARATOGA SARATOGA, CA 95070 CT I DATE ISSUED: 03/02/2011 PHONE NO: (408) 393-1785 BUILDING PERMIT INFO: BLDG I— ELECT r PLUMB f— MECH F RESIDENTIAL r COMMERCIAL r— JOB DESCRIPTION: RI MODEL BATHROOM (25SQFT) Sq. Ft Floor Area: I Valuation: $10000 APN Number: 32613049.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtainifig an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertjno Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(�) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Date• CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued( e 097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION 1 understand my plans Licensed Professional IM-7, CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 22265 carta blanca DATE: 03/02/2011 REVIEWED BY: larry s APN: BP#: "VALUATION: 1$10,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: PENTAMATION 1R3SFDREM PERMIT TYPE: WORK bathroom remodel SCOPE Xfcch. Plan Check Phunb. Plorr C'herk Elec. Plan Chcrt:.k FecbPcovill Fee: Plwnh. Pr, :. Fie: (:Icrc. Pcvniit Fcr Other ,L1ech. Insp. 01her f7rx. Insp. E3__L__ ;l/ech. limp. Fee: Nuwh. Iffsp. 1111- Oec. In�I, I'rc: NOTE. These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 09-051 Ef. .. 7/1/10) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 25 s.f. $570.00 Remodel, Bath (<=300 sf) 1REMRESBAT Suppl. PC Fee: E) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-.0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consowclion Tax Acoustical Fee: 0 Yes E) No $0.00 Q 0 Work Without Permit? 0 Yes E) No $0.00 Planning Fee: $0.00 Select a Non -Residential Building or Structure i Travel Doculnenturion F`c:es: Strong Motion Fee: IBSEISMICR $1.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $2.00 $570.00 'TOTAL FFE: F $572.00 Revised: 03101 /2011